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I 13 special _ endo-implant algorithm I roots1_2010 Numerous devices have appeared in the endo- dontic armamentarium to address this situation: _EndoVac (Discus Dental): a negative pressure dif- ferential device designed to deliver high volumes of irrigation solution while using apical negative pressure through the office high-volume evacua- tion system; _Negative Pressure Safety Irrigator (Vista Dental): device is similar to EndoVac; _Rinsendo (Air Techniques): uses pressure suction technology; 65 ml of irrigant are automatically drawnfromtheattachedsyringeandaspiratedinto the canal (pressure created is lower than manual irrigation); and _Vibringe (Bisco Canada): sonic flow technolo- gy facilitates enhanced irrigation through the myriad complexities of the root-canal system (Fig. 11). NaOClcannotdissolveinorganicdentineparticles and thus prevent smear layer formation during in- strumentation.29 Chelators, such as EDTA and citric acid, are recommended as adjuvants in root-canal therapy.Itisprobablethatbiofilmsaredetachedwith the use of chelators; however, they have little if any antibacterial activity. Several studies have demonstrated that citric acid in concentrations ranging as high as 50% were more effective at solubili- sation of inorganic smear layer components and powdered dentine than EDTA. In addition, citric acid has demonstrated antibacterialeffectiveness. Technologyandinnovation will not negate the need for op- timal preparation (debridement and disinfection) to eliminate microbial content and its impact on a necrotic root-canal system. We as a discipline need to improve; however, endodon- tics has shown its commitment to endless rein- vention. In time, this will restructure the role of natural teeth in foundational dentistry, currently diminished by the market forces of implant-driven dentistry. Ortho-biological replacement is not a panacea as random clinical trials increasingly show; the severity of peri-implantitis lesions demonstrates significant variability and as such no treatment modality has shown superiority. The pendulum will continue to swing as the endodontic implant algo- rithm becomes increasingly multivariate. _Microstructural replication—obturation Steven Covey is known for his book The Seven Habits of Highly Effective People. The habit most applicable to endodontics is the second one: “begin with the end in mind”. The implication of this vision with regard to idealising the final shape of the root-canal system in order to ensure that the obturation represents a totality is profound. The root canal is negative space and as such recovery of its original unaffected form is the sine qua non of obturation or more descriptively, microstructural replication. Perhaps the most significant ex- ample of negative space recovery is Michelangelo’sstatuaryforthefunerarycham- berofPopeJuliusII.Fourunfinishedsculpturesspeak eloquentlytothisprocess:thefigurewasoutlinedon the front of the marble block and then Michelangelo worked steadily inwards from this side, in his own words“liberatingthefigureimprisonedinthemarble”. This is an exacting description of debridement and instrumentationoftheroot-canalspacepriortoroot filling after a myriad of pathologic vectors have destroyed the dental pulp, and altered the morphol- ogy/topography of the system (Fig. 12). Incomplete filling of the debrided and sculpted root-canal space is one of the major causes of endodontic failure.30 Until recently, in vitro testing (dye leakage, fluid Fig. 9_Micro-etching ensures the removal of oils and debris, and the elimination of the residue in fusion lines and fissures. Routine dentine bonding is then performed. The composite selected in this instance is PermaFlo Purple (Ultradent Products, Inc.), which enables differentiation of restoration and tooth structure should re-entry be necessary. Fig. 10_There is a vast array of equipment on the market to optimise irrigation protocols. Radical change may well be in the offing; however, research and development on bio-active obturating materials may prove to be the defining variable in total asepsis. irrigation, agitation techniques and devices manual syringe irrigation needles/cannulas brushes manual dynamic agitation hand activation of gutta percha cone end vent side vent Endobrush NaviTip FX machine assisted pressure alteration devices rotary brushes EndoVac RinsEndo Ruddle brush Canalbrush rispisonic file EndoActivator sonic ProUltra PiezoFlow Ultrasonic Irrigation Needles Ultrasonic Irrisafe, Sonofile Fig. 9 Fig. 10